Provider Demographics
NPI:1417321209
Name:WADE, LYNNETTE
Entity Type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14527 S CALHOUN AVE
Mailing Address - Street 2:
Mailing Address - City:BURNHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60633-2207
Mailing Address - Country:US
Mailing Address - Phone:708-980-3097
Mailing Address - Fax:708-933-7138
Practice Address - Street 1:14527 S CALHOUN AVE
Practice Address - Street 2:
Practice Address - City:BURNHAM
Practice Address - State:IL
Practice Address - Zip Code:60633-2207
Practice Address - Country:US
Practice Address - Phone:708-980-3097
Practice Address - Fax:708-933-7138
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor